REVISED

WORK SESSION DOCUMENT

Legislative Committee on Health Care’s

Subcommittee to Study the Development of a System for Reporting Medical Errors

(Assembly Concurrent Resolution No. 7 [File No. 77, Statutes of Nevada 2001])

April 16, 2002

The following work session document has been prepared by staff of the Legislative Counsel Bureau. It is designed to assist the subcommittee members in determining which recommendations may be forwarded to the Legislative Committee on Health Care.

The possible actions listed in the document do not necessarily have the support or opposition of the subcommittee. These possible actions simply are compiled and organized so the members may review them to decide if they should be adopted, changed, rejected, or further considered. Sponsors of recommendations may be noted in parentheses.

In addition, Assembly Concurrent Resolution No. 7 [File No. 77, Statutes of Nevada 2001] specifies that no action may be taken by the subcommittee on recommended legislation unless it is approved by a majority of the members of the Senate and a majority of the members of the Assembly appointed to the subcommittee.

GENERAL RECOMMENDATIONS FOR STATEMENTS

1. Send a letter from the Legislative Committee on Health Care to the medical professional associations and organizations in this state urging them to create a Nevada Alliance for Patient Safety (NAPS). The NAPS would strive to achieve consensus on recommendations to promote systemic change within medical facilities to improve patient safety by discussing patient safety issues, encouraging sharing of best practices, creating documents and issuing press releases to the public on good patient behavior and for professionals on best practices. Membership of the NAPS would include all professional associations and organizations and advocacy groups that are willing to participate, with relevant state agencies invited to serve as advisory members. The NAPS would provide an annual report to the Legislative Committee on Health Care. See Exhibit A. (Recommended by Chairman John Yacenda.)

2. Send a letter from the Legislative Committee on Health Care to the Nevada Hospital Association urging the association to publicize to consumers and health care advocacy organizations information about the coordinated efforts of its members to promote patient safety and to create centers of excellence for best practices in order to share knowledge and experience as it relates to the prevention of medical errors and adverse events and the promotion of patient safety. (Recommended by Chairman John Yacenda.)

3. Send a letter from the Legislative Committee on Health Care to each licensed medical facility urging the facility to provide to each patient a statement referencing its mission to ensure a safe patient environment and to ensure that the rights of patients are recognized and respected. The telephone numbers for the facility’s safety director; the Bureau of Licensure and Certification, Health Division, Nevada’s Department of Human Resources; and the Joint Commission on Accreditation of Healthcare Organizations should also be provided to assist a patient who may have a question and to assist if an issue arises that the patient believes should be reported. (Recommended by Assemblywoman Bonnie L. Parnell; Bill Welch, Nevada Hospital Association, 4/5/02 correspondence.)

4. Send a letter from the Legislative Committee on Health Care to each licensed medical facility urging the facility to include in its admission package: (1) the telephone number and address for the Office for Consumer Health Assistance in the Office of the Governor and the Bureau of Hospital Patient Safety within the Office for Consumer Health Assistance; (2) information to assist a patient who may have a question and to assist if an issue arises that the patient believes should be reported; and (3) a copy of the Patient’s Rights provisions set forth in Nevada Revised Statutes. (Recommended by Assemblywoman Bonnie L. Parnell.)

5. Send a letter from the Legislative Committee on Health Care to all health profession licensing and oversight boards urging them to meet and coordinate their efforts to ensure and encourage patient safety by agreeing, to the extent authorized by law, to standardize their practices and policies for: (1) informing the public of professional licensees and how this information is provided to consumers; (2) accepting and investigating complaints from the public or other health care providers or institutions; (3) disclosing their findings to the public; and (4) disclosing the names of patients and professionals involved in the complaints and investigations. In the letter to the licensing boards, urge them to coordinate their policies relating to consumer and professional education through public service announcements, mailers, or partnering with appropriate agencies. Also, express in this letter that the licensing boards should propose and support changes to the Nevada Revised Statutes that would accommodate the standardization of their practices and policies. (Recommended by Chairman John Yacenda.)

6. Send a letter to the Legislative Committee on Health Care requesting the committee to not propose any changes to the state’s current methods of reporting potential violations of the state regulations and statutes that govern the practice of individual health care providers. See Exhibit B. (Recommended by the State Board of Nursing, 3/29/02 correspondence.)

7. Send a letter to the Legislative Committee on Health Care listing the legal implications and protections that should be considered in any action taken by the committee concerning the reporting of adverse events attributable to errors in the practice of medicine, dentistry, nursing, pharmacy, and care received at medical facilities, and urging the committee to consider these implications and protections. These implications and protections include, without limitation, qualified immunity, whistleblower protections, and confidentiality. (Recommended by Chairman John Yacenda.)

RECOMMENDATIONS FOR STATEMENTS

RELATED TO STATE AGENCY PROGRAMS

8. Send a letter from the Legislative Committee on Health Care to Nevada’s Department of Human Resources (DHR) urging the department to require, to the extent authorized by law, medical facilities that are not accredited by the Joint Commission on Accreditation of Healthcare Organizations to maintain a confidential file of certain sentinel events. This file would only be available to the licensure survey personnel of the Bureau of Licensure and Certification, Health Division, DHR, at the time of on-site surveys. (Recommended by Assemblywoman Bonnie L. Parnell; Robin Keith, Nevada Rural Hospital Project, 3/24/02 correspondence.)

9. Send a letter from the Legislative Committee on Health Care to Nevada’s Department of Administration, Nevada’s Department of Human Resources (DHR), and the chairmen and members of the Legislature’s Senate Committee on Finance and the Assembly Committee on Ways and Means, urging support for funding vacant positions in the Bureau of Licensure and Certification, Health Division, DHR. Also, send a letter urging the DHR and the Department of Personnel to review the position of a Health Facilities Surveyor and upgrade the requirements for all positions in this series to ensure expertise in the areas being surveyed. (Recommended by Assemblywoman Bonnie L. Parnell; Robin Keith, Nevada Rural Hospital Project, 3/24/02 correspondence; Bill Welch, Nevada Hospital Association, 4/5/02 correspondence; Mark VanderLinden, 3/27/02 correspondence.)

10. Send a letter from the Legislative Committee on Health Care to the Health Division of Nevada’s Department of Human Resources urging the division to require, to the extent authorized by law, hospitals to report medical errors, adverse events, preventable adverse events, adverse outcomes that are related to nurse staffing levels, and nurse-to-patient ratios. Also, urge the division to include, to the extent authorized by law, through progressive monetary penalties not to exceed $10,000, suspension or revocation of licensure and/or public disclosure of penalties for acute care facilities that fail to report medical errors, adverse events, preventable adverse events, adverse outcomes that are related to nurse staffing levels, and staffing levels. [MPT1] (Recommended by Maryanne Dawicki, Service Employees International Union, 3/29/02 correspondence.)

11. Send a letter from the Legislative Committee on Health Care to Nevada’s Department of Human Resources (DHR) urging the department to include in its proposed budget to the Office of the Governor funding to enhance the current database of the Bureau of Licensure and Certification, Health Division, DHR. The bureau would implement an Internet-based information system to permit health care providers access to information obtained by the bureau. (Recommended by Mark VanderLinden, 3/27/02 correspondence.)

12. Send a letter from the Legislative Committee on Health Care to Nevada’s Department of Human Resources (DHR) urging the department to require the Bureau of Licensure and Certification, Health Division, DHR, to annually review all regulations related to quality improvement and patient safety in health care facilities. Also, request the department to sanction facilities that do not comply with such regulations and do not address the issue within the required time frame. (Recommended by Assemblywoman Bonnie L. Parnell; Robin Keith, Nevada Rural Hospital Project, 3/24/02 correspondence.)

13. Send a letter from the Legislative Committee on Health Care to the Health Division of Nevada’s Department of Human Resources urging the division to consolidate the efforts of its Bureau of Licensure and Certification and Bureau of Health Planning and Statistics to generate a consolidated report detailing all deaths and adverse outcomes attributable to errors in the practice of medicine, dentistry, nursing, pharmacy, and care received at medical facilities. The report would be submitted to the Nevada Alliance for Patient Safety, if such an alliance were created as urged in the first recommendation, for review, analysis, abstraction, and dissemination of findings. (Recommended by Chairman John Yacenda.)

14. Send a letter from the Legislative Committee on Health Care to the Division of Health Care Financing and Policy of Nevada’s Department of Human Resources, requesting the division to submit quarterly reports to the Nevada Alliance for Patient Safety (of which Nevada Medicaid would be an advisory member), if such an alliance is created as urged in the first recommendation, of the division’s response and follow-up to the Drug Utilization Review Board’s actions identifying beneficiaries of assistance provided by or administered by the division who are potentially at risk for drug therapy problems, and the manner in which the division is ensuring that actions are being taken to prevent drug therapy problems among these beneficiaries. (Recommended by Chairman John Yacenda.)

15. Send a letter from the Legislative Committee on Health Care to Nevada’s Department of Human Resources (DHR) and the chairmen and members of the Legislature’s Senate Committee on Finance and the Assembly Committee on Ways and Means urging support for funding $3 million over the 2003-2005 biennium to the Bureau of Licensure and Certification, Health Division, DHR, to conduct on-site annual reviews of all medical facilities to ensure that the requirements contained in the Nevada Administrative Code relating to quality of care and patient safety are being satisfied. (Recommended by Bill Welch, Nevada Hospital Association, 4/5/02 correspondence.)

16. Send a letter from the Legislative Committee on Health Care to the Insurance Commissioner of the Division of Insurance, Nevada’s Department of Business and Industry, urging the commissioner, to the extent authorized by law, to consider mandated discounts for professional liability insurance premiums when hospitals, physicians, and others participate in a state-sponsored health collaborative. (Recommended by Mark VanderLinden, 3/27/02 correspondence.)

17. Send a letter from the Legislative Committee on Health Care urging Nevada’s Department of Human Resources (DHR) to adopt the reporting and investigating mechanism for adverse events of the Division of Mental Health and Developmental Services, DHR, as a model for all publicly funded programs of medical, dental, and psychological care administered by the department. (Recommended by Chairman John Yacenda.)

GENERAL RECOMMENDATIONS FOR LEGISLATIVE MEASURES

18. Request the drafting of a bill appropriating $100,000 to fund the development and maintenance of a statewide medical adverse event surveillance system. This system should be developed by a private agency with expertise in patient safety and health care data analysis using existing vital statistics and electronic hospital discharge data supplemented with targeted review of medical records. (Recommended by Michael P. Silver, HealthInsight, 3/27/02 correspondence.)

19. Request the drafting of a bill requiring professional licensing boards to keep reports of medical errors confidential. This measure would allow the boards to release information to the public only after a potential violation is confirmed and disciplinary action is taken against a licensee. (Recommended by Bill Welch, Nevada Hospital Association, 4/5/02 correspondence.)

20. Request the drafting of a bill appropriating $11 million for the first year and $5 million for the next year to fund the University and Community College System of Nevada programs for licensed health care professionals with an emphasis on nursing. (Recommended by Assemblywoman Bonnie L. Parnell; Bill Welch, Nevada Hospital Association, 4/5/02 correspondence; Robin Keith, Nevada Rural Hospital Project, 3/24/02 correspondence.)

RECOMMENDATIONS FOR LEGISLATIVE MEASURE CONCERNING

REPORTING SYSTEMS FOR REPORTING MEDICAL ERRORS

Mandatory Medical Error Reporting Systems

21. Request the drafting of a bill establishing a mandatory medical error reporting system requiring preventable medical errors, adverse events, adverse outcomes that are related to nurse staffing levels, and nurse-to-patient ratios to be reported by hospitals to the Bureau of Licensure and Certification, Health Division, Nevada’s Department of Human Resources. Provide that the reporting system includes nurse staffing information and public access to all mandatory reports. Under this system, the directors of risk management and/or quality improvement of hospitals would be required to submit the information to the Bureau of Licensure and Certification. See Exhibit C. (Recommended by Maryanne Dawicki, Service Employees International Union, 3/29/02 correspondence.)

22. Request the drafting of a bill establishing a mandatory medical error reporting system that includes the following elements:

(a) An anonymous and confidential reporting system, which would protect the identity of the patient and health care practitioner;

(b) Coordination by the Division of Health of Nevada’s Department of Human Resources (DHR) to act as a data repository and facilitate information flow, communication, and task allocation among regulatory bodies;

(c) Aggregation of facility performance data with disclosure of aggregated data through annual and accessible public reports;

(d) Performance of a thorough follow-up and analysis of internal facility processes utilized to identify and improve medical error and quality-of-care issues by the Bureau of Licensure and Certification, Health Division, DHR;

(e) Protection of information in the report from subpoena or discovery process in legal actions; and

(f) Limitation of $50,000 in recoverable damages in medical malpractice actions in which errors have been reported in good faith.

(Recommended by Nina Carter, Health Research/Product Manager, HealthMarketInsights, 4/1/02 correspondence.)

23. Request the drafting of a bill specifically authorizing each county whose population is 400,000 or more to establish and maintain a medical error reporting system. See
Exhibit D. (Recommended by Donald S. Kwalick, M.D., Clark County Health District, 3/29/02 correspondence.)

Voluntary Medical Error Reporting Systems

24. Request the drafting of a bill establishing a voluntary medical error reporting system that would include information concerning adverse events to analyze current trends and enhance or improve best practices. This system would require data from medical facilities to be reported to a central repository. A state agency or a private agency under contract with the state would manage the repository. Information submitted to the repository would remain confidential. Require protection from legal discovery of the data in the system. (Discussed at the February 2002 meeting during the interim; recommended by subcommittee members.)

25. Request the drafting of a bill establishing a voluntary medical error reporting system that would include information concerning adverse events and near misses to identify hazardous conditions, practices, and linkages in health care. This system would include secure Web-based capability with its design adapted from the Aviation Safety Reporting System maintained and run by the National Aeronautics and Space Administration. Require this system to be integrated with existing and national reporting systems and also have the ability to support analysis of conditions of concern locally. Any information reported to this system must remain confidential and protected from legal discovery. See Exhibit E. (Recommended by Michael P. Silver, HealthInsight, 3/27/02 correspondence.)

26. Request the drafting of a bill appropriating $300,000 to ensure credible and thorough analysis of data of voluntary reports received by a private agency with expertise in patient safety and health care data analysis, effective feedback to the reporting community, and timely dissemination of information to health care providers. Funding considerations should include the development and maintenance of analysis, feedback, and dissemination of information received through the voluntary reporting system. (Recommended by Michael P. Silver, HealthInsight, 3/27/02 correspondence).

27. Request the drafting of a bill establishing a voluntary, anonymous, and confidential medical error reporting system. Require protection of reported information from subpoena or discovery process in legal actions. A centralized data system established and run by a private, independent organization would collect the reported information. The organization would issue reports quarterly to the public. See Exhibit F. (Recommended by Beatrice Razor, 3/7/02 correspondence.)

28. Request the drafting of a bill establishing within the Bureau of Licensure and Certification, Health Division, Nevada’s Department of Human Resources, a complimentary, voluntary reporting program providing confidentiality and protection to participating caregivers and hospitals if a mandatory medical error reporting system is established as set forth in Recommendation 21. Information collected through this system would not be publicly available. Hospitals would be required to share this information to prevent medical errors and adverse outcomes. (Recommended by Maryanne Dawicki, Service Employees International Union, 3/29/02, correspondence.)

29. Request the drafting of a bill requiring Nevada’s Department of Human Resources (DHR) to establish an Internet-based registry for an anonymous, voluntary, password-protected, standardized incident reporting system and registry. Hospitals, long-term care facilities, ambulatory surgery centers, and other related facilities would be authorized to input confidential information into the registry. The system would track adverse events attributable to errors in the practice of medicine, dentistry, nursing, pharmacy, and medical facilities. Participation in the registry would be voluntary. The system would be operated by a private agency under contract with the DHR. The establishment of the reporting system would be dependent on state funding or grants, gifts, endowments, bequests, or direct appropriation for its creation. See Exhibit G. (Recommended by Chairman John Yacenda.)

Other

30. Send a letter to the Legislative Committee on Health Care recommending to the committee that the State of Nevada not develop a mandatory reporting system for medical errors, adverse events, or sentinel events. (Recommended by Michael P. Silver, HealthInsight, 3/27/02 correspondence.)

31. Send a letter to the Legislative Committee on Health Care recommending to the committee that the State of Nevada not develop an external medical error reporting system until internal reporting systems in health care facilities are identified and remediated. (Recommended by Lisa Black, Nevada Nurses Association, 4/4/02 correspondence.)

32. Request the drafting of a resolution providing for an interim study to continue identifying and reviewing internal reporting systems in health care facilities. The study might consider system failures to determine whether they contribute to medical errors. The study may also examine the changes that are necessary in an internal reporting system to effectively implement an external reporting system. (Recommended by Lisa Black, Nevada Nurses Association, 4/4/02 correspondence.)